You may want to protect yourself living in a country like Cambodia. There are lots of hazards here. The main danger is on the roads. The commonest infection to visitors, aside from tummy upsets is dengue fever. The locals have invented ways of protecting themselves against all kinds of threats.
My first patient was wearing a string amulet around her waist to keep her from falling sick especially during the barang’s operation! I thought it must be some magic device. It had to be moved a bit to perform the spinal anaesthetic and I’m afraid it got rather a lot of iodine on it during the skin prep, but it wasn’t all that clean anyway so it simply went a shade or two darker brown. The doctor on the post-op ward round the other day told off another patient whose amulet string was lying across her wound because of the risk of infection.
My defence methods against infection have been a little less magical and more scientific although I’m not sure they have been any more effective.
At the weekend I visited several temple sites in the extreme north-east of the country with my friend Oly from Thmar Puok. The area of Banteay Chhmar where there is an attractive ruined temple has many trees and many mosquitos. The large stripy mosquito which carries dengue fever bites in the daytime and since there is no treatment or vaccine the only thing to do is to avoid being bitten. We liberally applied DEET spray 50% to our exposed areas of arms, legs, neck and bald patch and augmented the spray with DEET wipes as evening approached.
In the forested areas we tried not to stand still for long and we listened out for the tell-tale sound of the big mosquito. Unfortunately the small ones are silent unless they pass by the ear, and they don’t cause pain when they bite so there’s no chance to swat one you didn’t hear or see. The lump swells and itches after – that’s when you know you’ve been bitten.
At Banteay Chhmar the tumbled blocks fallen from the temple walls are home to lizards and snakes. They rustle in the fallen dry leaves among the blocks and we soon found it was wise to stay on top of the blocks and make plenty of noise when we saw our first snake. It was black with white side stripes and partly hidden under a block of sandstone. It wriggled away when it knew we were there. After that we were cautious where ever we tread and noisy, stamping on the blocks to disturb any others. All we heard after that was rustling in the leaves as we approached and all we saw were lizards and butterflies.
It wasn’t until the afternoon after the taxi dropped me back in Mongkul Borei that I realised how many bites I had all over my legs. They seem to choose a certain time of day to start itching and then they itch like crazy! Antihistamine cream works really well and in the evening I took an antihistamine tablet. There are two possible sources of these bites.
In the evening in Thmar Puok we had borrowed a second bike and went for a ride out of the village in a large circuit from one hamlet to another, through the Wat (pagoda and monastery) where we chatted to the monks who are learning English. I didn’t apply any DEET as I reckoned mosquitos wouldn’t land and bite on legs that were pedalling furiously along. Unfortunately the bicycle chain kept coming off as it was old, worn and stretched. After the third time I found a dried palm frond at the roadside and we used it as a tow rope. Oly sat on the leafy end on his bike seat and I held the fat stem and we made good progress that way for a few kilometers. It worked really well as it was long enough to allow me to steer my own course around the bumps and potholes on the dirt road, and it produced lots of smiles and laughter from the Khmer folk who overtook or passed us going in the other direction. In the next hamlet the cycle repair man (there’s at least one in every place) adjusted the rear wheel to take up the slack and we were fine. We paid 1,000 Real, 25 cents, for the fix, not bad service for 5 o’clock Sunday afternoon, and were off again no problem. I was especially pleased because I had been able to say in Kmai ‘I have a problem with my bike!’
The trouble with the mosquitos was that I hadn’t been pedalling while I was being towed and the mechanical problems had delayed us so we didn’t get home until after dark. We met a baby snake on the road at dusk but he wasn’t very scary, just minding his own business (or her’s – how do you tell if a snake is a girl or a boy? – does anybody know? Has anyone found out and lived to tell the tale?). So I may have been bitten at dusk but I also wonder whether there were fleas in the taxi which took refuge inside my rather baggy walking trouser legs and enjoyed a good meal on the 2 hour journey bone-jarring journey from Thmar Puok while I was concentrating on other things.
The hospital in Thmar Puok is smaller than Mongkul Borei and refers difficult maternity cases to us for Caesarean or blood transfusion. It was very quiet there on Sunday. The one member of staff on duty woke up on hearing us arrive. He showed us the only maternity patient who had been admitted with abdominal pain but was getting better and hoping to go home the next day. She works at Halo which has its district headquarters in Thmar Puok because this area was heavily mined being close to the border and one of the areas where the Khmer Rouge remained active for a long time after the war was supposed to be over. Known minefields are well signed and the locals generally know where it is safe or unsafe to be. We visited Halo HQ after the hospital and saw examples of the bombs dropped by American planes as well as the booby traps and landmines they have been recovering. They have had no fatalities among their workers here because of good protective visors and body armour. They don’t rely on magic.
The guy looking after the hospital shop does however. His stall is in the grounds of the hospital and sells everything the patients and visitors need. He was a soldier fighting against the Khmer Rouge. He proudly displays his tattoos done in 1978 to protect him from the bullets. The bullets are deflected or turn to water. They seem to have done so in his case at least.
Another hospital worker was also a soldier although you wouldn’t imagine it if you met him today. He describes a firefight at the hospital when Vietnamese soldiers were holding the hospital compound against the Khmer Rouge advancing along the road the other side of the temple moat and he was lobbing mortars over the moat in their direction. Some of the palm trees around the hospital are still riddled with bullet holes.
Back in civilised Mongkul Borei, in the maternity ward, the spirit house in the courtyard is used to protect patients in labour. The relatives of the labouring patient will light incense sticks and leave food and drink offerings to the spirits to make sure the birth goes well. The spirits are the departed souls who have died in the place so I’m not sure how effective it has been in the past. Every home has a spirit house in the garden to cater for the departed souls and to ensure good luck. Not having one is likely to incur the displeasure of neighbours who may be at risk because of your carelessness. This magic is not part of Buddhism which is the major religion here. It belongs in animism and superstition but it sits alongside the religion, especially for the poor and uneducated.
The strange thing is, in this culture, although suffering is not good, death is no problem, for then the cycle of rebirth and life starts all over. And that’s one of the reasons for the general lack of concern and action in the face of danger, the kind of danger faced by the patient in labour and the unborn child, for in this manner of thinking, there is another chance at life, and another, and another – ad infinitum.
Education and wealth have had little impact on this way of thinking and therefore do no more to improve the prospects for maternal and child health than the amulet, or the tattoo, or the spirit house does …